ML20056E212

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Summary of Operating Reactors Events Meeting 93-21 on 930609
ML20056E212
Person / Time
Site: Salem, Indian Point  Entergy icon.png
Issue date: 06/15/1993
From: Chaffee A
Office of Nuclear Reactor Regulation
To: Grimes B
Office of Nuclear Reactor Regulation
References
OREM-93-021, OREM-93-21, NUDOCS 9308200279
Download: ML20056E212 (19)


Text

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _

. . g JUN 151993 .

w w MEMORANDUM FOR: Brian K. Grimes, Director Division of Operating Reactor Support FROM: Alfred E. Chaffee, Chief Events Assessment Branch Division of Operating Reactor Support

SUBJECT:

OPERATING REACTORS EVENTS BRIEFING JUNE 9, 1993 - BRIEFING 93-21 On June 9, 1993, we conducted an Operating Reactors Events Briefing (93-21) to inform senior managers from offices of the Commission, EDO, NRR, AEOD, RES, and regional offices of selected events that occurred since our last briefing on June 2, 1993.

Enclosure 1 lists the attendees. Enclosure 2 presents the significant elements of the discussed events.

Enclosure 3 contains reactor scram statistics for the week ending June 6, 1993. No significant events were identified for input into the NRC performance indicator program.

l

- original signed by Robert L. Dennig for -

Alfred E. Chaffee, Chief Events Assessment Branch Division of Operating Reactor Support

Enclosures:

As stated DISTRIBUTION:

Central Files cc w/ attachments: PDR See next page LKilgore, SECY EAB R/F KGray RDennig EGoodwin l DSkeen l EBenner Y&

9: OR y NRR EAB: DORS:NRR 1RR KGray EGoodwin AC a fee l (d? /\ D/93 /, / /93 ( / /V/ 936 L #l/ g< a . l OFFICIAL RECORD COPY DOCUMENT NAME: ORTRANS.KAG (G:KAG) hl g/l 090028 NRC F1E CENTER COPY

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PDR ORG NRRB PDR i lU c~ .

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cc:

T. Murley, NRR (12G18)

F. Miraglia, NRR (12G18)

J. Stont (PD1-2)

C. Miller (PD1-2)

F. Gillespie, NRR (12G18)

J. Partlow, NRR (12G18) i S. Varga, NRR (14E4)

J. Calvo, NRR (14A4)

G. Lainas, NRR (14H3)

J. Roe, NRR (13E4)

J. Zwolinski, NRR (13H24)

E. Adensam, NRR (13E4)

W. Russell, NRR (12G18)

J. Richardson, NRR (7D26)

A. Thadani, NRR (8E2)

S. Rosenberg, NRR (10E4)

C. Rossi, NRR (9A2)

B. Boger, NRR (10H3)

F. Congel, URR (10E2) .

D. Crutchfield, NRR (11H21)

W. Travers, NRR (11B19)

D. Coe, ACRS (P-315)

E. Jordan, AEOD (MN-3701)

G. Holahan, AEOD (MN-9112)

L. Spessard, AEOD (MN-3701)

K. Brockman, AEOD (MN-3206)

S. Rubin, AEOD (MN-5219)

M. Harper, AEOD (MN-9112)

G. Grant, EDO (17G21)

R. Newlin, GPA (2G5)

E. Beckjord, RES (NLS-007)

A. Bates, SECY (16G15)

G. Rammling, OCM (16G15)

T. Martin, Region I W. Kane, Region I C. Hehl, Region I S. Ebneter, Region II E. Merschoff, Region II S. Vias, Region II J. Martin, Region III E. Greenman, Region III J. Milhoan, Region IV B. Beach, Region IV B. Faulkenberry, Region V K. Perkins, Region V bec: Mr. Sam Newton, Manager Events Analysis Department Institute of Nuclear Power Operations 700 Galleria Parkway Atlanta, GA 30339-5957 ,

A.

. m.k ENCLOSURE 1 l

LIST OF ATTENDEES OPERATING REACTORS EVENTS FULL BRIEFING (93-21)

JUNE 9, 1993 NAME OFFICE NAME OFFICE A. CHAFFEE NRR G. ZECH NRR E. BENNER NRR A. THADANI NRR K. GRAY NRR S. LONG NRR S. WITTENBERG NRR R. JONES NRR E. GOODWIN NRR P. ENG NRR R. DENNIG NRR M. DAVIS NRR J. WERMIEL NRR B. BUCKLEY NRR N. CONICELLA NRR A. KUGLER NRR l R. CAPRA NRR R. GALLO NRR B. GRAMM NRR J. DEBOR NRR N. CAMPBELL NRR J. SCARBOROUGH OCM/KR l M. CHATTERTON NRR M. FLEISHMAN OCM/KR J. STONE NRR B. DOOLITTLE J. CALVO OCM/FR ,

NRR V. BENAROYA AEOD J. PARTLOW NRR l D. WHEELER OEDO C. MILLER NRR R. GREGER OEDO C. GRIMES NRP J. MURPHY RES M. RING NRR i

TELEPHONE ATTENDANCE (AT ROLL CALL)  :

l Recions Resident Inspectors l Region I j Region II  !

Region III Region IV Region V IIT/AIT Tean Leaders Misc. l W. Ruland, Region I l

ENCLOSURE 2 OPERATING REACTORS EVENTS BRIEFING 93-21 LOCATION: 10 B11, WHITE FLINT WEDNESDAY, JUNE 9, 1993, 11:00 A.M.

SALEM, UNIT 2 R0D CONTROL SYSTEM SINGLE FAILURE POTENTIAL (AIT)

VARIOUS PLANTS SOFTWARE ISSUES l

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PRESENTED BY: EVENTS ASSESSMENT BRANCH l DIVISION OF OPERATING REACTOR  !

SUPPORT, NRR l 1

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O O 93-21 SALEM, UNIT 2 R0D CONTROL SYSTEM SINGLE FAILURE POTENTIAL (AIT)

JUNE 6, 1993 PROBLEM SINGLE FAILURE IN THE R0D CONTROL SYSTEM COULD RESULT IN  !

WITHDRAWAL OF ONE OR MORE RODS IN A GROUP WHEN OTHER RODS WERE BEING INSERTED.

CAUSE DESIGN WEAKNESS AND P00R MAINTENANCE PRACTICES.

SAFETY SIGNIFICANCE R0D WITHDRAWAL 0F THIS NATURE MAY RESULT IN EXCEEDING FUEL DESIGN LIMITS AND LOCALIZED FUEL DAMAGE.

CHRON0 LOGY OF EVENTS MARCH 30, 1993: l o WESTINGHOUSE R0D CONTROL PREVENTATIVE MAINTENANCE SERVICE COMMENCES.

o SOME PROBLEMS FOUND AND CORRECTED: TYPICAL TYPES AND NUMBERS PER WESTINGHOUSE EXPERIENCE.

MAY 26, 1993: I o DEVELOPED CONTROL BANK C COUNTER PROBLEMS. i o CIRCUIT CARDS REPLACED DUE TO DIODE FAILURES.

CONTACTS: W. RULAND, REGION I/DRS AIT: YES E. BENHER, NRR/ DORS SIGEVENT: TBD

REFERENCE:

10 CFR 50.72 #25609

l

  • O SALEM, UNIT 2 93-21  ;

MAY 27, 1993:

o SHUTDOWN BANK A WITHDRAWN, NO R0D MOVEMENT INDICATED  !

WITH COUNTER AT 20 STEPS. i o RODS INSERTED T0 6 STEPS, R0D ISA3 OBSERVED INDICATING 8 STEPS ON ANALOG R0D POSITION INDICATION (ARPI).  ;

o SHUTDOWN BANK A RODS INSDiTED TO ZER0 STEPS ON COUNTERS, R0D ISA3 INDICATING 15 STEPS ON ARPI.  !

o FOUND AND REPLACED TWO DEFECTIVE SLAVE CYCLER CARDS.

MAY 28, 1993:

o ALL RODS WITHDRAWN WITH CONTROL BANK D AT 160 STEPS.

o CONTROL BANK C GROUP 1 DROPPED, INITIATED MANUAL TRIP.

o FOUND AND REPLACED DEFECTIVE FIRING CARD CIRCUITRY.

o DURING MAINTENANCE RETEST, POWER SUPPLY FUSES BLOWN.

o MULTIPLE FAILURES CAUSED BY POWER SUPPLY SHORT.

JUNE 2, 1993:

o P-TO-A CONVERTER AND PLANT COMPUTER INDICATED ZER0 STEPS ON CONTROL BANKS B AND D.

o FOUND AND REPAIRED DEFECTIVE CIRCUIT CARD. j JUNE 4, 1993:

o NRC QUESTIONED SINGLE FAILURE DESIGN.

o MANAGEMENT DIRECTS SHUTDOWN TO MODE THREE.

DISCUSSION i WESTINGHOUSE SPECIAL MAINTENANCE ACTIVITY BEING PERFORMED l DUE TO PAST GENERIC CONCERNS.

(I CD  ;

SALEM, UNIT 2 93-21 l COMMUNICATIONS ON PAST EVENTS- I o NUREG/CR-1331, " DATA SUMMARIES OF LICENSEE EVENT l REPORTS OF CONTROL RODS AND DRIVE MECHANISMS AT U.S.

COMMERCIAL NUCLEAR POWER PLANTS" ,

o NUREG/CR-5555, " AGE ASSESSMENT OF WESTINGHOUSE PWR  ;

CONTROL R0D SYSTEMS." l FOLLOWUP PUBLIC SERVICE ELECTRIC AND GAS: l o PLACED UNIT 2 IN HOT STANDBY.

o PLACED UNIT 1 R0D CONTROL IN MANUAL AND DEVELOPED STANDING ORDERS ON TRANSIENT RESPONSE.

JUSTIFICATION FOR CONTINUED OPERATION PREPARED DUE TO TRIP DN JUNE 8, 1993, LICENSEE WILL NOT RESTART UNIT UNTIL R0D CONTROL ISSUE IS RECTIFIED  !

o MADE NPRDS OPERATING EXPERIENCE ENTRY ON JUNE 5, 1993.

PLANS TO UPDATE ENTRY TODAY WESTINGHOUSE:

o P0TENTIAL INCIDENT PROCESS HAS BEEN ACTIVATED ON l JUNE 8, 1993.

o GENERIC APPLICABILITY CONFIRMED.

NUCLEAR REGULATORY COMMISSION:

o REGION I SENT A SPECIALIST INSPECTOR TO THE SITE.

o AN AUGMENTED INSPECTION TEAM HAS BEEN DISPATCHED TO THE SITE.

o CONTACTED REGULATORY RESPONSE GROUP 0F THE WESTINGHOUSE OWNER'S GROUP ON JUNE 8, 1993.

o COMMISSIONERS' ASSISTANT BRIEFING PERFORMED.

o EXPEDIENT INFORMATION NOTICE BEING DEVELOPED.

o CONFIRMATORY ACTION LETTER GENERATED.

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O e SALEM, UNIT 2 93-21 o PLAN TO CONTACT COMBUSTION ENGINEERING AND BABCOCK AND WILCOX AS WELL, IN THE NEAR TERM.

o NEED FOR ADDITIONAL ACTION BEING EVALUATED.

INP0:

o SIGNIFICANT EVENT NOTIFICATION BEING DEVELOPED.

1 I

O O 93-21 SOFTWARE ISSUES AT NUCLEAR POWER PLANTS JUNE 9, 1993 SALEM OVERHEAD ANNUNCIATOR (OHA)

A. BACKGROUND

1. WHILE AT 100% POWER 12/13/92, SALEM UNIT 2 OHA DID NOT UPDATE ALARMS FOR 1.5 HOURS. WHEN OPERATORS REALIZED THIS, THEY RESET OHA COMPUTER AND RESTORED OPERATION.
2. NRC INSPECTION TEAM FOUND:

SAFETY AREA HARDWIRED PANEL ALARMS BACKUP HOWEVER, UNDETECTED LOSS OF OHA COULD DELAY OPERATOR RESPONSE DESIGN SPECIFICATION DEFICIENCIES COMPUTER-HUMAN INTERACTION DEFICIENCIES B. SYSTEM DESCRIPTION

1. REAL-TIME, HIGH SPEED DISTRIBUTED MULTI-MICR0 PROCESSOR SYSTEM
2. HARDWARE SEQUENTIAL EVENT RECORDER (SER)

REDUNDANT PROCESSORS IN HOT STANDBY FAILOVER CONFIGURATION i SCANNER CARDS TIME TAG ALARMS DISTRIBUTED LOGIC PROCESSORS l REDUNDANT PROCESSORS FOR ALARM WINDOWS  ;

REMOTE CONFIGURATION WORKSTATION (RCWS)

COMMANDS & DATA TO CONFIGURE SYSTEM COMMANDS TO RETRIEVE DATA FROM SYSTEM CONTACT: E. BENNER, NRR/ DORS

O O SOFTWARE ISSUES 93-21

3. SOFTWARE  :

SEQUENTIAL EVENTS RECORDER (SER) l VEND 0R SPECIALIZED DESIGN PROGRAMS l RUN UNDER PURCHASED MULTITASKING OPERATING SYSTEM PROGRAM l DISTRIBUTED LOGIC PROCESSORS l VENDOR SPECIALIZED DESIGN PROGRAMS  :

REMOTE CONFIGURATION WORK STATION (RCWS) l VENDOR SPECIALIZED DESIGN PROGRAMS j COMMERCIAL 0FF-THE-SHELF (C0TS) PROGRAMS  !

. l C. FINDINGS: DESIGN AREA  !

1. INADEQUATE SPECIFICATION / REVIEW 0F THE SYSTEM SOFTWARE REQUIREMENTS 4 N0 SOFTWARE DESIGN REVIEW N0 TOP LEVEL SOFTWARE DESIGN SPECIFICATION NO INTEGRITY CHECKS ON DATA TRANSFER FOR MAJOR SYSTEM BLOCKS NO TRANSITION TO A KNOWN STATE UPON PROCESSOR SUSPENSION OF PROCESSING INCONSISTENT INDICATION OF SYSTEM STATUS UNDER ALL PROCESSING CONDITIONS SEQUENCE AND PRIORITY OF PROCESSING UNDER NORMAL, ABNORMAL AND HAZARD CONDITIONS MISSING DIAGNOSTIC RESULTS NOT MADE AVAILABLE FOR USE ON THE DISTRIBUTED LOGIC PROCESSORS

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SOFTWARE ISSUES 93-21 D. FINDINGS: COMPUTER-HUMAN INTERACTION AREA NO CLEAR, DIRECT INDICATION TO OPERATOR OF SYSTEM STATUS UNDER ALL CONDITIONS INCORRECT DATA LINK USAGE ALLOWED WITH NO FEEDBACK TO OPERATOR DATA LINK INPUT TO COMPUTER NOT COMPREHENSIVELY PROTECTED AGAINST:

KEYB0ARD ERRORS EXCESSIVE TIME WAITING FOR DATA OR COMMANDS COMMAND SEQUENCE TRANSPOSITIONS COMMAND MNEMONIC INDEPENDENCE & CONSISTENCY E. FINDINGS: OPERATION & MAINTENANCE AREA 0 & M PERSONNEL NOT ALERTED TO DEBUG PHASE OF DIGITAL SYSTEMS EVEN AFTER TURNOVER TRANSIENT BUGS PREVALENT, RECOGNITION AND SYSTEMATIC APPROACH HEEDED l

O O

SOFTWARE ISSUES 93-21 INDIAN P0 INT 3 ATWS MITIGATION ACTUATION CIRCUITRY (AMSAC)

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A. BACKGROUND INSTALLED IN 5/89 TO CONFORM WITH 50.62 ATWS RULE.

AT POWER ON 1/12/93, IP3 DETERMINED AMSAC IN0PERABLE DUE TO WRONG SOFTWARE VERSION INSTALLED SINCE 7/8/92.

NRC DETERMINED AMSAC NOT END-TO-END TESTED SINCE INITIAL INSTALLATION, AND CONDUCTED FURTHER ,

DETAILED INSPECTIONS IN THE DESIGN AREA.

IP3 DECIDED TO SHUTDOWN 2/26/93 TO REVIEW, TEST  !

AMSAC.

INSPECTION RESULTS:

AMSAC DID NOT FULLY MEET ATWS RULE SINCE INITIAL INSTALLATION.

CRITICAL PART OF SOFTWARE MISSING.

B. SYSTEM DESCRIPTION

1. HARDWARE FOXBOR0 INTELLIGENT AUTOMATION (I/A) PRODUCTS
2. SOFTWARE l FOXBOR0 I/A SOFTWARE LIBRARY C. FINDINGS: DESIGN AREA
1. INCORRECT TRANSLATION OF SYSTEM REQUIREMENTS TO SOFTWARE VEND 0R CRITICAL SEAL-IN OF TIME DELAY VALUE AS A NON-LINEAR FUNCTION OF TURBINE POWER AT LOW FLOW CONDITIONS NOT SPECIFIED WOULD CAUSE AMSAC TO NOT FULFILL INTENDED FUNCTION

O O

SOFTWARE ISSUES 93-21

2. N0 SOFTWARE DESIGN REVIEW ACCEPTED VENDOR-GENERATED CONTROL BLOCK SCHEMATICS D. FINDINGS: OPERATION & MAINTENANCE AREAS
1. ACCEPTANCE TESTS NOT COMPREHENSIVE  !

COMPREHENSIVE TESTS WOULD HAVE TESTED CRITICAL TIME DELAY VALUE SEAL-IN REQUIREMENT

2. INADEQUATE SOFTWARE CONFIGURATION AND DISK CONTROL CAUSED LOSS OF AMSAC FUNCTION FOR APPR0X SIX MONTHS WRONG SOFTWARE VERSION
3. SOFTWARE MAINTENANCE NOT CONTROLLED
4. HARDWARE FAILURE INDICATIONS PROVIDED BY VENDOR NOT USED BETWEEN SURVEILLANCE PERIODS FOR ERROR DETECTION ,
5. PASSWORD FOR SOFTWARE ENTRY NOT CONTROLLED 1

l SOFTWARE ISSUES 93-21 NRC GENERIC ACTIONS i

1 INFORMATION NOTICES:

A. " ANNUNCIATORS" i e SALEM LOSS OF ANNUNCIATORS B. 92-06, SUPPLEMENT 1, " RELIABILITY OF ATWS MITIGATION SYSTEMS AND OTHER NRC-REQUIRED EQUIPMENT NOT CONTROLLED BY PLANT TECHNICAL SPECIFICATIONS" e INDIAN POINT 3 AMSAC FAILURES C. " PROBLEMS WITH DIGITAL CONTROL CONSOLE SYSTEMS AT NON-POWER REACTORS" e TRIGA REACTOR DIGITAL CONTROL SYSTEM AN0MALIES AT ARMED FORCES RADI0 BIOLOGY RESEARCH INSTITUTE AND PENNSYLVANIA STATE UNIVERSITY D. " IMPROPER INTEGRATION OF SOFTWARE INT 0 OPERATING I

PRACTICES" e INDIAN POINT 3 AMSAC FAILURES

  • SALEM LOSS OF ANNUNCIATORS i e MAINE YANKEE DIVERSE SCRAM SYSTEM FAILURE e FITZPATRICK IN0PERABLE TORUS TEMPERATURE MONITORING SYSTEM

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SOFTWARE ISSUES 93-21 1

INSPECTION ACTIVITIES: i i

I e REGION I HAS DEVELOPED AN INSPECTION PROGRAM TO l ASSESS THE ADEQUACY OF SOFTWARE INTEGRATION AT l POWER REACTORS. l J

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ENCLOSURE 3 o REACTOR SCRAM o ,

j Reporting Period: 05/31/93 to 06/06/93 )

l YTD YTD ABOVE BELOW YTD E PtaET & Uhfi PMR IIf1 cat /SE CTMPL IC AY10NS JH .ill TOTAL I l

D$/31/93 PILCRIM 1 25 SA Ecpipment Failure NO 2 0 2 ,

l 06/03/93 MILLS 10*iE 2 100 SA EqJipnent Failure No 3 1 4 i i

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3: Year To Date (YTD) Totals tretixle Events Within The Calendar Tear Indicated By The Erd Oste of The specified acporting Feriod 10 Page:1 06/09/93

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- . w COMPARISDN OF WEEKLY SORAM STATISTICS WITH IkDUSTRY AVERAGE 5 PERIOD ENDikG 06/D6/93 NUMEER 1993 1992 1991* 1990* 1989*

OF WEEKLY WEEKLY WEEKLY WEEKLY WEEKLY SCRAN CAUSE SCRAw.S AVERAGE AVERAGE AVERAGE AVERAGE AVERAGE (YTD)

POWER GREATER THAN OR EQUAL TO 15%

EQUIPMENT FAILURE

  • 2 2.1 2.6 2.9 3.4 3.1 DESIGN /INSTALLATIDW ERROR
  • O 0.1 - - - -

CPERAT!kG ERROR

  • 0 0.4 0.2 0.6 0.5 1.0 MAINTEAAACE ERROR
  • 0 0.5 0.4 - - -

EXTERAAL* O 0.1 - - - -

OTHER* O 0.0 0.2 - -

0.1 S *totst 2 3.2 3.4 3.5 3.9 4.2 POWER LESS THAN 15%

EQUIPMENT FAILURE

  • 0 0.4 0.4 0.3 0.4 0.3 DESIGW/1kSTALLAT10W ERROR
  • 0 0.0 - - - -

OPERATING ERROR

  • O 0.2 0.1 0.2 0.1 0.3 MAlWTENAACE ERROR
  • 0 0.0 0.1 - - -

EXTERAAL* O 0.0 - - - -

OTHER* O 0.0 0.1 - - -

5 4tetet 0 0.6 0.7 0.5 0.5 0.6 TOTAL 2 3.8 4.1 4.0 4.4 4.8 1993 1992 1991 1990 1989 WO. OF WEEKLY WEEKLY WEEKLY WEEKLY WEEKLY SCRAM TYPE SCRAMS AVERAGE AVERAGE AVERAGE AVERAGE AVERAGE (YTD)

TCT AL AUTOMATIC 5: RAMS 2 2.5 3.1 3.3 3.2 3.9 YOTAL MANUAL $0 RAMS 0 1.2 1.0 0.7 1.2 0.9 10 Tats MAY DIFFER EECAUSE OF ROUND!hG OFF

  • Detailed breerdo.n not in datatese for 1991 and earlier

- EETERAAL cause included in EQUIPMENT FAILURE

- MAlkTEkANCE EEROR and DESIGW/lkSTALLATION ERROR causes iretu:$ed in OFERAT!WG ERROR

- CTHER cease inctu:$ed in EQUIPMEWT FAILURE 1991 eM 1990 14 Page: 1 06/09/93

e. .

)TEF .

. PLANT SPECIFIC DATA BASED ON INITIAL REVIEW OF 50.72 REPORTS FOR THE WEEK OF INTEREST. PERIOD IS MIDNIGHT SUNDAY THROUGH MIDNIGHT SUNDAY.

. SCRAMS ARE DEFINED AS REACTOR PROTECTIVE ACTUATIONS WHICH RESULT IN ROD MOTION, AND EXCLUDE PLANNED TESTS OR SCRAMS AS PART OF PLANNED SHUTDOWN '

IN ACCORDANCE WITH A PLANT PROCEDURE. THERE ARE 111 REACTORS HOLDING AN OPERATING LICENSE.

. PERSONELL RELATED PROBLEMS INCLUDE HUMAN ERROR, PROCEDURAL DEFICIENCIES, '

AND MANUAL STEAM GENERATOR LEVEL CONTROL PRO 3LEMS.

COMPLICATIONS: RECOVERY COMPLICATED BY EQUIPMENT FAILURES OR PERSONNEL ERRORS UNRELATED TO CAUSE OF SCRAM.

"OTHER" INCLUDES AUTOMATIC SCRAMS ATTRIBUTED TO ENVIRONMENTAL CAUSES (LIGHTNING), SYSTEM DESIGN, OR UNKNOWN CAUSE.  ;

i OEAB SCRAM DATA l

.nual and Automatic Scrams for 1987 ------------------

435

.nual and Automatic Scrams for 1988 ------------------ 291

.nual and Automatic Scrams for 1989 ------------------ 252 '

.nual and Automatic Scrams for 1990 ------------------ 226 '

nual and Automatic Scrams for 1991 ------------------ 206

.nual and Automatic Scrans for 1992 ------------------ 212

.nual and Automatic Scrans for 1993 --(YTD 06/06/93)-- 83 I

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